LFP Longform: What have we learned from Wettlaufer inquiry so far?

If the 51-year-old Woodstock woman hadn't confessed to the killings, and to four attempted murders and two aggravated assaults in the fall of 2016, the system — and all its faults — might have just carried on.

When Elizabeth Wettlaufer pleaded guilty to killing eight elderly, vulnerable residents at two Southwestern Ontario nursing homes, she revealed herself to be a violent, troubled nurse — the worst killer in the history of Canadian health care.

What’s not so widely known, however, is how the environment within Ontario’s vast long-term care system, made up of more than 600 homes caring for more than 70,000 people, turned out to be fertile ground for Wettlaufer’s murder spree.

If the 51-year-old Woodstock woman hadn’t confessed to the killings, and to four attempted murders and two aggravated assaults in the fall of 2016, the system — and all its faults — might have just carried on.

Instead, if anything meaningful can come from the horror Wettlaufer inflicted by administering deadly insulin overdoses at the nursing homes and while providing home care, it will be from the provincial inquiry into long-term care that just ended its eighth week in St. Thomas, its last before it moves to Toronto next month for its final phase.

Commissioner Eileen Gillese, a judge on Ontario’s highest court, has heard evidence about how the system operates, the policies and guidelines it’s supposed to follow and the people who work within it.

So far, what’s emerged is a portrait of a broken system that failed to catch up with a woman who’d been fired twice, admitted drug use and mental health issues, and yet had good standing in her profession.

It’s not pretty:

Too few staff, too many residents

Coroners failing to see the need for autopsies on the elderly

A bureaucracy more intent on policy creation than concrete actions.

The inquiry was called in the wake of Wettlaufer’s court case a year ago to figure out how the former nurse — sentenced to life in prison, with no chance of parole for 25 years — was able to carry on her crimes undetected for so long.

She committed the murders over seven years, from 2007 to 2014, killing seven residents of Caressant Care in Woodstock and one at Meadow Park in London.

It will take years to fix the system that Wettlaufer exploited.

With most of the testimony now in, we asked some people involved with the inquiry, or with interests in it, what they see as the biggest takeaways so far and how it might lead to improvements.

DORIS GRINSPUN

Chief executive, Registered Nurses Association of Ontario (RNAO)

The RNAO was the first organization to call for the inquiry after Wettlaufer was sentenced. Grinspun said she has no regrets. “More and more I think we did the right thing. I would do it all over again.”

When Wetllaufer’s murders became public, the RNAO and other health-care workers were “devastated that one of our own can do such a brutality,” she said. Nurses from across Ontario called her with horror stories of neglect in long-term care homes, she said, mostly because of a lack of adequate staffing.

The idea was to put the spotlight on the care inside the homes.

“Without an (inquiry), we never could have put all the pieces together,” she said. “Leave no stone unturned and do the best we can so it never happens again.”

Grinspun said the inquiry has pointed to the need for coroners to be more willing to do autopsies on the aged. But she’s been most “pleasantly impressed” by the exposure of low staffing levels in the homes.

“I was afraid it might be put under the carpet, but it’s been raised by everybody,” she said.

There’s been evidence the ratio of residents to nursing staff is painfully lacking, sometimes one registered nurse for every 300 residents in some large homes.

In general, “you really have only nine per cent (registered nurses), 19 per cent (registered practical nurses) and the rest are all unregulated (staff) . . . you wouldn’t have that staffing anywhere else.“

Also heard at the inquiry is how inspectors are sent to homes to investigate what’s wrong. “The whole approach to inspection, the whole approach to funding is a punitive approach,” Grinspun said.

She said funding is often reduced when a home improves after inspections, with the residents becoming healthier — for example, with less incontinence, fewer falls and fewer pressure ulcers,

“If Premier (Doug) Ford andHealth and Long-term Care Minister (Christine) Elliott want to do something very right here, they should focus on the funding model and revamp the funding model,” she said.

What’s clear to Grinspun is that ageism – a prejudice against the elderly – is “very true, but it’s true first and foremost by the government.”

“If the government is serious about making a difference in the next four years, it’s not just the hallway nursing,” she said, referring to reports of people lingering in hospital hallways awaiting treatment that Ford has vowed to end. “It is the situation of our vulnerable people in nursing homes. Most of them can’t speak for themselves.”

The key flaw, she said, is that people are asked to self-report issues but are penalized for it. “We’re expecting people to report something when their future could depend on them not reporting it.”

Her overall impression is that the system is subject to “over-regulation and a lack of information.”

“I think we want to make ourselves feel good that we’re doing something, so let’s pass a regulation,” she said. But all that means is more paperwork for staff, instead of caring for residents.

She hopes one outcome of the inquiry will be “a system of spontaneous checks,” which will be followed up. Spot checks on care facilities would trigger a better way to focus than simply collecting information and “then missing pretty, darned obvious red flags,” she said.

“We need a fundamental transformation of how we do long-term care,” she said.

PAUL SCOTT

One of the lawyers representing families of Wettlaufer victims

The initial shock for the families of nursing home residents murdered by Wettlaufer cut deep and the inquiry, Scott said, has sent more tremors through their lives.

“Obviously, a lot of the revelations that are coming out are hard to hear,” he said.

“There’s almost nobody more important to you than your mother and when you’re responsible for placing them in somebody else’s care and then you find out you placed them in the care of a murderer, then that’s tough. There’s just no way to get over that hurdle.”

One of his clients, Beverly Bertram, survived an insulin overdose Wettlaufer gave her when she was supposed to be giving Bertram home care.

“Imagine finding out that somebody had tried to kill you,” he said. “That’s a shocking, shocking thing and it’s tough to get over that idea.”

Still, Scott said, there are reasons for the families to have hope. “I think this is having some positive effects for my clients in that they are seeing that sunlight is being let into this and we’re finding out the deficiencies and I’m hopeful we’re going to fix it.”

The main takeaways, he said, are low staffing and funding levels in long-term care homes.

“Every single aspect so far that I’ve heard comes back to this issue – nurses and (staff) bodies in the long-term care homes to take care of people, not just at a basic level, but at a level we would want our loved one to be taken care of.”

But what’s clear is that had Wettlaufer not confessed, “I don’t think there is a shred of evidence that would have linked her to it.”

“Every single person that has been up on the stand and has been asked the question, ‘Did you have any indication’, have all answered the same way: ‘No, of course not.’ ”

JANE MEADUS

Counsel, Ontario Association of Residents’ Councils, an umbrella group for residents councils in long-term care homes

“What we really are finding is there were numerous people in positions of power and authority who had obligations to do things they didn’t do,” she said.

“For example, people didn’t report things about Ms. Wettlaufer that should have been reported. The coroner did not do proper investigations of deaths that should have been investigated, where there was evidence that there were issues.”

No one knew Wettlaufer was a murderer, but there were enough of “all these little things” that should have been reported to the Ministry of Health and Long-term Care and College of Nurses of Ontario, she said.

“There were serious concerns about her professionalism, the services she was providing, (and) she was abusing patients by not providing them with care. She was neglecting them by not providing them pain medication and people knew about this and they were not reporting that to the ministry.”

The revelations of failures to report problems are just “the surface,” she said.

The province has “this robust legislation,” she said, but if there aren’t proper inspections, or people don’t file complaints, often because they don’t know they can, “it just adds to this whole problem.”

“We really need to look at it, because, unlike a daycare, you’re not picking your child up at the end of the day. That person is there 24-7, usually 365 (days) and it’s a different system all together.”

And because many of those same people are vulnerable, often with dementia, they can’t speak out.

“Even though there seems to be more scrutiny and a lot more legislation, in fact, there probably is less focus,” she said.

MARK ZIGLER

Co-counsel for the commissioner

The first eight weeks of the inquiry was “to get the story of what happened,” Zigler said.

“Not so much from Wettlaufer’s perspective, because she had that when she was sentenced, but from the perspective of how the system failed to deter or catch her or detect anything,” he said.

The main takeaway, he said, “is let’s look forward now. What can we do to deter and detect these sorts of crimes?”

“There’s no guarantee that there will never be another Wettlaufer, but what protections can you put into the system to make sure that happens?,” he said. “And, hopefully, all the participants will focus on that.”

While what’s emerged so far are a variety of issues and concerns in long-term care, “the commissioner’s job isn’t to wave a magic wand and fix everything in the system.”

The focus must turn back to the people who were murdered and harmed by a registered nurse, the person who should have been the most trusted in their care.

The commissioner, he said, has taken the approach that allows everyone “to say their piece.”

At closing submissions, the victims’ families will have a chance to speak.

The commissioner’s job, Zigler said, will be to make recommendations to the government about what can be done to protect long-term care residents and home-care patients from a potential murderer.

“That’s what this is about. It’s pretty serious stuff. You think it’s simple, but it’s not,” he said.

“There should be an awareness that this thing can happen and we shouldn’t just take the system for granted and say that this will never happen again.

“If you know this can happen, that’s Step 1. And Step 2 is what can you do.”

This Week's Flyers

Comments

We encourage all readers to share their views on our articles and blog posts. We are committed to maintaining a lively but civil forum for discussion, so we ask you to avoid personal attacks, and please keep your comments relevant and respectful. If you encounter a comment that is abusive, click the "X" in the upper right corner of the comment box to report spam or abuse. We are using Facebook commenting. Visit our FAQ page for more information.